Sunday, November 13, 2011

Is Postpartum Psychosis an Autoimmune Disease?

Here's an article for the "everything is connected" file. Also for "yes, psychiatric disease has biologic underpinnings and is medical illness" file. Also the "inflammation in the wrong place at the wrong time is super-bad" file. And it may be of interest to anyone who has had symptoms of autoimmune disease helped by an anti-inflammatory (paleo-type) diet.

Postpartum psychosis is rare and scary. About 1 in 1000 women become psychotic in the first months after having a baby (though anything up to 12 months after is considered "postpartum" the greatest risk is in the first month). The most typical presentation is one of manic psychosis, with prominent insomnia, irritability, and delusions of grandeur. However, some women will also be depressed and be delusional and suicidal, or even with delusions that lead a women to kill her baby.

Not surprisingly, a prior diagnosis of bipolar disorder is the greatest risk factor for developing postpartum psychosis. However, most women with postpartum psychosis have no history of psychiatric illness at all (1). Often the illness requires hospitalization, and though there are no "consensus treatment guidelines," in almost all cases benzodiazepines (sedative, anti-anxiety meds, such as lorazepam) are used to help stabilize sleep-wake cycles, and in most cases antipsychotics are also used, typically with good effect. If those aren't helping, lithium is added.

Here's another bit of info about pregnancy. The fetus is obviously genetically different than mom, so women develop a depressed immune system during pregnancy, in order to protect the growing beastie from mom's antibodies and killer cells. This is why I was told to studiously avoid unpasturized cheese and raw eggs and deli meat during pregnancy, and why healthy women in the third trimester are much more likely to develop severe complications and die from the flu than women who are not pregnant.

It is well known that in women with a dysfunctional immune system (the autoimmune diseases, such as multiple sclerosis, rheumatoid arthritis, and autoimmune thyroiditis), the autoimmune symptoms are generally greatly ameliorated during pregnancy. However, this time of relatively low autoimmune symptoms is followed in the post-partum period by a "rebound" with greatly increased symptoms and greater autoantibody titers measured in the serum.

So is post-partum psychosis a symptom of autoimmune disease? Specifically autoimmune thyroid disease, as thyroid disease (both hyper- and hypothyroidism) is well known to cause psychiatric symptoms, even psychosis?

Well, those societies with socialized medicine were able to gather data in such a way as to start to give us an answer to that question. In the Netherlands, all the women in a certain area of the country who developed post-partum psychosis and ended up in the hospital were checked for autoimmune thyroid antibodies and thyroid function upon admission to the hospital. A larger control group of other post-partum women were also checked. Critically, women who were medicated at admission (particularly with lithium) were excluded from the study, as lithium is known to depress thyroid function. All women with a previous history of thyroid disease, bipolar disorder, schizophrenia, or psychosis were excluded. That left a group of 29 women with new-onset post-partum psychosis and 117 controls.

Here is what the researchers found. 5% of post-partum women in the control group had measurable autoimmune thyroid autoantibodies at 4 weeks after delivery, a sign of autoimmune thyroid disease. This is comparable to surveys of a general population of women in the Netherlands. None of them had measurable abnormalities in thyroid function or any symptoms. In contrast, 19% of the post-partum psychosis patients had measurable thyroid autoantibodies at admission (again, prior to receiving any lithium or antipsychotic medication treatment), and half of those women also had measurable thyroid abnormalities. In the following 9 months, 67% of the postpartum psychosis women with autoimmune thyroid antibodies went on to develop measurable thyroid problems (abnormal TSH or free thyroxine). None of the control women did. The odds ratios for these findings were all >2, some as large as 9, which is quite significant, especially considering the size of the sample).

Even though patients with previous bipolar disorder were excluded from this study, the researchers note that the 19% prevalence of autoimmune thyroid antibodies in these psychotic women is similar to the prevalence in women with bipolar disorder (2). And, to really get your noggins going, twin studies of bipolar disorder show that the presence of autoimmune thyroid antibodies are correlated not only to the illness itself, but to the genetic vulnerability to the illness (3).

The researchers in this study strongly recommended that all women with postpartum psychosis be monitored for thyroperoxidase antibodies and thyroid function abnormalities, and furthermore that all women at high risk for postpartum psychosis be monitored before and throughout pregnancy and the postpartum period. Though this was a small observational study, the advice seems very reasonable.

And, as always, we find that "post-partum psychosis" like many psychiatric symptoms is the equivalent of a fever - signaling underlying abnormalities, but not always caused by the flu. Sometimes fevers are caused by different bugs, or cancer, or autoimmune disease. Differentiating the underlying pathology will go a long way to informing our treatments (and helping in prevention) in the future.

14 comments:

Interesting study. It raises the possibility that the 'tolerance' developed to that little foreign object (baby) during pregnancy seems to have repercussions for some women when the immune system is 'reset' post-partum? Couldn't have anything to do with the drain on vits, minerals and fatty acids which those little nippers cause to poor old mum? Seem to remember something about the fatty acid side of things particularly depletion and postpartum depression: http://www.sciencedirect.com/science/article/pii/S0753332206003465(bearing in mind that lots of other mechanisms might pertain).

Evidence suggests progesterone is mood stabilizing and antiepileptic (and estrogen is the opposite, known to trigger mania and seizures)... so abrupt withdrawal (e.g. havin' a bay bay) in vulnerable women could hypothetically trigger crazy times.

I mean, speaking personally take it for what you will, almost every menstrual cycle, upon w/d of progesterone, I experence a marked increase in energy and mood elevation, which is rather striking and strange as most women seem to report "PMS" (which is something I have never experienced). This stimulant-like increase in energy doesn't always happen, but it usually does, to some degree. My body speeds up, I feel very energetic, and I will have changes in how I think, more intensely and emphatically. I will feel high.

There is a phenomenon called menstrual psychosis, which is considered a variant of bipolar, and represents manic insanity with the highs and lows of progesterone. This is similar to catamenial epilepsy, which also mirrors the highs and lows of progesterone (except, instead of manias and depressions the patient experiences seizures/remissions). Basically the highs of estrogen = crazy/seizures and the highs of progesterone = inhibition of that, and the w/ds of progesterone = crazy/seizures.

I suspect that in PP psychosis, one possibility is that certain women are uber sensitive to the mood destabilizing effects of progesterone withdrawal, and this triggers manic psychosis.

Women with known bipolar have rapid cycling presentations more often than male patients specifically because estrogen and progesterone trigger bipolar episodes.

Being pregnant/on progesterone is sorta like taking inhibitory/gabaergic psych meds for 9 months and then cold turkeying them. Some spaz out is a risk due to the fact the brain is adaptive to the inhibitory / estrogen blocking aspects of progesterone. And, estrogen being such a powerful mood boosting hormone, will often trigger depressions upon w/d (as in giving birth). Both mania and depression and all sorts of nuttery can happen.

The fact so many women showed to have abnormalities in thyroid function, perhaps suggests that psychotic disorder may be a symptom of abnormal thyroid functioning? I always thought thyroid disorder was one of those illnesses that can look like bipolar or unipolar depression, as it plays havoc with thinking speed and energy. This doesn't seem to suggests a problem with autoimmunity in specific, it seems to suggest that a whole lot of people who have thyroid illness are being treated as mentally ill when it is likely their "bipolar" would go away if their thyroid situation was properly handled.

Very well put comment on an intriguing article! Yes, there is a big link to progesterone. IMO, the underlying reasons that postpartum anxiety and depression are allowed to present themselves are also related to depressed glandular function of all types; not just thyroid. Women have many barriers to proper function, including toxicity blocking receptor sites, inadequate nutrient intake, low oxygenation of the blood and even other common issues like parasites.The progesterone issue is a huge key to this puzzle.

Good post, Emily. With a Bipolar I mother, brother and sister (the latter diagnosed after a manic episode post partum with her first child), and numerous relatives w thyroid abnormalities, the subject meshes with many personal observations and family debates.

I had my own first child at 31 after quixotically having myself vetted to be sure I had not inherited the family curse (think Cary Grant saying: I'm not a Brewster after all, I'm the son of a sea cook!" in "Arsenic and old Lace"--kids born into crazy families often love them but sometimes pray that they are adopted.

I was fortunate and had healthy experience after all 3 live births. I am married, and nursed all 3 kids on demand, without supplements and stayed home by choice for the first eight years , so had little role stress. I missed my profession a lot (hospital chaplain workiing w abused kids and adolescents) but loved being a mom.

I did, however, fall into a deep depression after the death in mid pregnancy of our third child, which was much more than normal grief. I received no medical care as my spouse was unemployed and we had no insurance (my spouse was afraid that if I talked to a shrink, we would be turned down for private health insurance.

I got pregnant with our fourth (third living) child three months after the miscarriage and immediately the depression lifted tho I was still sad about the loss. But no longer ill.

One area that should be explored is the impact upon the mother's mental health of exclusive breastst feeding. Also upon her autoimmune function. The effects upon the infants are well known. My experience was that the years I spent nursing were calm, happy, physically healthy, and the first time I had been free of depression since I was 14. Nursing made me more loving . Perhaps I needed the hormonal help more than most given the lack of positive maternal role models in my fily?

But I do believe that postpartum problems in women tending towards depression (like me) are helped by exclusive nursing. Manic types like my mother and sister are going to go off anyway, but should still nurse for the good of the babies, even if the mother has to be watched the first six months (as my sister was). Also, given how mood disorders can trash the maternal infant bond at times, I view nursing as especially important for women with unstable family or personal histories. Anything that makes mom feel good will be good for the baby

Just some observations, I don't mean this iPhone tapped comment to sound too prescriptive! And my sister's awesome kids are living proof that bipolar people can have great kids: one a barrister and professor, one a pediatrician.

I'm glad to see research being done somewhere on postpartum mental illnesses. I'd like to see your take on prenatal mental illnesses as well. I suffered from prenatal depression and anxiety when I was pregnant. The anxiety part was particularly uncharacteristic for me. I was prescribed Prozac by my doctor, who was not a psychiatrist and did not follow up with me. It caused me to be more anxious, and I stopped taking it. I had never taken anti-depressants before. I would wake in the morning with a full on panic attack at least 50% of the time. In hindsight, I suspected that something was off with my cortisol levels, but had no clue what to do about it. I'd like to be pregnant again, but after that nightmare of an experience, it's not high on my list of things to do!

A good friend of mine, in fact a highly intelligent woman, had a severe case of this some 45 years ago which required several months of hospitalization. She had never had any mental issues before or any after. I don't know if it's relevant, but she died suddenly at age 60 of a heart attack, though she had had no known heart problems.

Okay, I'm comment bombing this excellent article by this point (I never comment this much on the net!). This article has made a HUGE impact on me- I love the line of inquiry. I would have to say yes, IMO they are absolutely related. I see magnesium deficiency in most all of my postpartum clients. The data shows that most people are deficient; and new moms have just donated all the nutrients needed to baby.A heart attack is basically a tragic, giant muscle spasm. Most muscular tension, spasms can be alleviated with adequate amounts of supplemental calcium/magnesium/vitamin D.

Mmm 23 years ago I had my first child, a boy unexpectedly early spontaneous labour at 35 weeks, he was 6 lb 5 oz. We now know I was gestational diabetic and his difficulties post arrival were due to a big sugar crash. I became extremely depressed and didn't bond with him due to delivery room trauma (forceps no pain relief etc) - I did however exclusively breastfeed; made no difference to bonding. I've only sorted that issue out in the last few weeks through TCM acupuncture.

Second baby, a girl 19 years ago, another spontaneous labour 35 weeker but only 5 lb 12, she had no problems, normal untraumatic delivery; at 29 weeks glucose was checked and I was diet controlled diabetic thence forth. No diabetes post partum, but big depression again. I fully breastfed her as well. No bonding issues.

I did suffer with bipolar - now sorted through Primal diet and a lot of meditation/acupuncture/yoga. I'm hugely sensitive to sugar (and dairy protein and alcohol).

My paternal grandmother through whom I appear to have acquired the tendency for bipolar and the sugar issues was manic depressive, hospitalised on numerous occasions particularly post partum (2 births) and died aged 58 from complications of uncontrolled diabetes (fatty infiltration of the heart).

For me we receive a genetic blueprint which predisposes us to a variety of issues given the 'trigger' environments. The closer I live to how my ancestors evolved 10,000 plus years ago the more healthy my expression of that blueprint appears to be.

Kudos to you for exploring underlying issues related to PPP. How refreshing! From the number of comments I've made, your article obviously impacted me greatly- I have a huge heart for new moms. I help women address perinatal mood and anxiety issues (except for PPP) with no medications, so I have some insight into methods that work to impact underlying imbalances.

I have also blogged about organic causes of psychiatric illnesses at WellPostpartum.org. Very interesting links to physical illness!

One company, True Hope has formulated a nutritional supplement called Empower Plus that has helped over 12,000 people (not new mothers) resolve their bipolar disorder without the use of medications. Intriguing work and data being produced by those folks.

When we explore possible underlying issues everyone wins. I appreciate that you are looking, as am I.

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About Me

Emily Deans, M.D.: I'm a psychiatrist in Massachusetts searching for evolutionary solutions to the general and mental health problems of the 21st century. Disclaimer: This information is for educational purposes only, and is in no way intended to be personal medical advice. Please ask your physician about any health guidelines seen in this blog, as everyone is different in his or her medical needs.